Provider Demographics
NPI:1083060032
Name:REYES, VERONICA GUADALUPE (LMT)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:GUADALUPE
Last Name:REYES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 W IRONWOOD DR STE 302
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4903
Mailing Address - Country:US
Mailing Address - Phone:208-664-5225
Mailing Address - Fax:208-664-5228
Practice Address - Street 1:850 W IRONWOOD DR STE 302
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4903
Practice Address - Country:US
Practice Address - Phone:208-664-5225
Practice Address - Fax:208-664-5228
Is Sole Proprietor?:No
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-1834225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID7215412814OtherTAX ID NUMBER